Facilitators and barriers of implementation of routine postnatal care guidelines for women: A systematic scoping review using critical interpretive synthesis

Background Postnatal care (PNC) has the potential to prevent a substantial burden of maternal and newborn morbidity and mortality. This scoping review aimed to identify and synthesise themes related to facilitators and barriers of implementation of guidelines on routine PNC for women (postpartum care) in all settings. Methods This is a scoping review guided by the standard principles of Arksey & O’Malley’s framework. We used the critical interpretive synthesis method to synthesise the whole body of evidence. We searched four databases (Medline, Embase, Global Health, CINAHL Plus) using a combination of search terms comprising four key concepts: postnatal care, routine care, guidelines and implementation. No restrictions on country or language of publication were applied. We excluded studies not presenting findings about PNC for women. We thematically charted the themes of studies included based on title and abstract screening. All studies included after full text screening were described and their results synthesised using the socio-ecological model framework. We did not conduct a risk of bias analysis or quality assessment of included studies. Results We identified a total of 8692 unique records and included 43 studies which identified facilitators and barriers to implementing routine guidelines in provision of PNC to women. Three quarters of studies pertained to PNC provision in high-income countries. Specific facilitators and barriers were identified and thematically presented based on whether they affect the provision of PNC or the intersection between provision of PNC and its use by women and families. We applied a critical global health lens to synthesise three constructs in the literature: finding a balance between standardisation and individualisation of PNC, the fragmented PNC provision landscape complicating the experiences of women with intersecting vulnerabilities, and the heavy reliance on the short postpartum period as an opportunity to educate and retain women and newborns in the health system. Conclusions This interpretive synthesis of evidence shows that the fragmented and narrow nature of PNC provision presents specific challenges to developing, adapting and implementing routine PNC guidelines. This results in a lack of linkages to social support and services, fails to address intersecting vulnerabilities and inequities among women, and negatively influences care seeking. There is a lack of evidence on how processes of individualising PNC provision can be applied in practice to support health workers in providing woman-centered PNC in various global settings. Registration https://www.protocols.io/private/C99DA688881F11EBB4690A58A9FEAC02


Rationale 3
Describe the rationale for the review in the context of what is already known.Explain why the review questions/objectives lend themselves to a scoping review approach.

3-4
Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.

4, ref 34
Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.
Information sources* 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.

and SM2
Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.

SM2
Selection of sources of evidence † State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.

4-5 and SM3
Data charting process ‡ 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made.5 Critical appraisal of individual sources of evidence § If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).

Synthesis of results 13
Describe the methods of handling and summarizing the data that were charted.5

Selection of sources of evidence 14
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.6, Figure 1, and SM4 Characteristics of sources of evidence 15 For each source of evidence, present characteristics for which data were charted and provide the citations.
Table 1 and  SM5 Critical appraisal within sources of evidence 16 If done, present data on critical appraisal of included sources of evidence (see item 12).

Not applicable
Results of individual sources of evidence 17 For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.9-11, Figure 2 and 3 Synthesis of results 18 Summarize and/or present the charting results as they relate to the review questions and objectives.11-12

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

13-14
Limitations 20 Discuss the limitations of the scoping review process.15

Conclusions 21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review.Describe the role of the funders of the scoping review.
16 JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.* Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites.† A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies.This is not to be confused with information sources (see first footnote).‡ The frameworks by Arksey and O'Malley (6) and Levac and colleagues (7) and the JBI guidance (4,5) refer to the process of data extraction in a scoping review as data charting.§ The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision.This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).B: Busy and chaotic nature of postnatal war and the lack of flexibility in meeting individ women's needs (difficult to tailor care to ea woman given the required checking, educa and documentation that had to be underta during relatively short hospital stays).Staffi constraints and external visitors added to th difficulties in providing women-centred car Low skills and confidence of midwives in providing some elements of PNC, for examp psychosocial assessment and support.Abse of guidelines on mental health screening.Priority of physical health issues over comp psychosocial issues.Physical layout of units women-baby dyads per postnatal room) an small communities mean lack of privacy and confidentiality for sensitive discussions. 5 Canada

Shea et al (2011)
To examine whether the implementation of a reminder system improved screening rates.

Yes
Element of PNC: Postpartum screening for type 2 diabetes for women with GDM at 3 months after birth Hospitals B: Poor communication between obstetrici and primary care provider; providers uncer about screening recommendations; patient unaware of the risk of not screening, patien missing screening appointments due to competing time commitments.F: Greater number of contacts with health c providers increases screening rates.F: 'Doing the right thing at the right time' approach: recognition of the need to target content and timing of care and provision of information offered as a continuum across pregnancy, birth and the postnatal period.Support for breastfeeding commenced with antenatal information, with subsequent clin care and processes to support breastfeedin promoted immediately following birth, with midwives on the labour ward asked not to transfer women for at least two hours follo the birth to enable women to have longer 'quiet' time with their babies to initiate skin skin care.

Multicountry
Literature review No Element of PNC: Screening for diabetes 6 weeks up to 6-12 months postpartum Multiple B: Discrepancy in guideline recommendatio for postpartum screening.Fragmentation o medical care from the prenatal to postpartu period contributes to lack of screening as t women are transitioned from obstetrical ca and/or specialist care during the pregnancy and returned to their primary-care provider the postpartum period (obstetrical provide takes responsibility for the postpartum visit may not be perceived as being responsible diabetes screening postpartum, lack of communication toward primary care provid Lack of health insurance coverage (benefits at 6 weeks postpartum, impedes access to screening afterwards).Logistics of the OGTT test (fasting and long time) means it is infrequently carried out in routine practice.

Intervention
Topic (routine, one element, specific target group)

PNC setting Barriers (B) and facilitators (F) identifie
To assess the rationale for screening postpartum and the barriers that have led to low screening rates.
Women do not return for postpartum scree and this particularly affects women at highe risk of T2DM.Barriers include lack of aware of the need for the test, a perception of goo health and not needing further care, afraid being diagnosed with diabetes, negative experiences with care received during their pregnancy, and time and logistics factors to attend an OGTT.
F: Reminders and scheduled visits to health providers postpartum can improve postpar testing rates.

USA and Greece
To describe recently published models and their core components, discuss barriers and facilitators to implementing such models, and highlight future practices and research needed to reduce the effects of maternal depression on mothers, families, and children.

Literature review No
Element of PNC: Screening and management of maternal depression in pediatric services Primary (pediatric) B: Billing for maternal mental health treatm in pediatric primary care and funding for co located care coordinators, case managers, a mental health providers are major systemslevel barriers to effective implementation.

F:
Training of providers; availability of in ho mental health services; effective referral tracking systems; engaging physicians and/ mothers in meaningful education; expectin universal screening with easy access to screeners; and easy link to co-located or community-based care managers or social workers to facilitate a smooth referral process.

S5. Table of 43 included studies, sorted by topic and year of publication First author (year of publication), reference Country Study objective(s) Study design, methods, population/source of data Inter- vention Topic (routine, one element, specific target group) PNC setting Barriers (B) and facilitators (F) identifie Topic: One element of routine postnatal care
Raising awareness and knowledge of postpartum care among healthcare provide through training, meetings, and clinical pra builds confidence and created empowerme and agents of change and this was central t the mobilization of resources related to staffing, space, and equipment.Educationa displays produced from locally available materials to display key contents of the guidelines (in spaces where providers and women can see them).Improvement of the documentation of care and communication Women's perspectives: Some women we very frustrated trying to organise out of hospital postpartum care themselves; inabi to choose preferred midwife within midwif network (other women did not have concre ideas or expectations about the midwife an were not challenged with the impersonal organisation of care); accessibility and relia of the midwife (women became nervous if was difficult to reach the midwife or if she d not adhere to meeting times and was late).to choose clients cl to the midwife's home or to other patients therefore to keep route short (logistics); ho visits allow deep insight into family lives an individualised support with vulnerabilities observed.The midwifery network interface with the hospitals about the follow-up supp offered to families and could be extended t relay feedback to the hospital about wome and their children who, according to midwi assessment, left the hospital in a poor state health. F: